Chapter 9, 10, and 13

How may a nurse demonstrate cultural competence when responding to clients in pain?

Avoid stereotyping responses to pain by clients.

The nurse is assisting a woman who is a victim of intimate partner violence in preparing a plan for leaving the relationship. Which of the following instructions would the nurse include? Select all that apply. "Be sure to have some type of identification, like a photo ID or a driver's license." "Take the deed to the house or your apartment lease with you." "Don't worry about your clothes; just get yourself out right away." "Get some phone cards that you can use to make the necessary calls." "Set up a specific plan for leaving and then practice it."

"Be sure to have some type of identification, like a photo ID or a driver's license." "Take the deed to the house or your apartment lease with you." "Set up a specific plan for leaving and then practice it." Rationale: When leaving an abusive relationship, a victim should take with her a driver's license or photo ID, the deed to the house or apartment lease, and a change of clothes for herself and her children. She should develop a game plan for leaving and then rehearse it. The woman should not use phone cards because they can leave a trail the abuser can follow.

The nursing instructor is educating her students on the important of assessing for victims of abuse and violence. What statement by the students indicate an understanding of when to assess for abuse and violence?

"I will assess a client for abuse and violence with every client encounter." Rationale: Routine assessment for violence and safety is important during every encounter with clients because of the high prevalence of human violence and its short- and long-term effects on health, relationships, and well-being.

A client was administered PO pain medications at 1530. By what time should the nurse re-assess and document the effects of the pain medication?

1630 Rationale: The JCAHO has set a standard that states that nurses must assess and reassess pain regularly. Most hospitals have a standard timeframe for reassessment, such as 1 hour for oral medication and 30 minutes for pain medication given intravenously. They base these timeframes on the time it takes a pain medication to provide a noticeable decrease in pain intensity.

The nursing instructor is teaching a class about how to assess pain in older adults. The teachers tells the students that problems can arise in certain circumstances. The instructor realizes the need for more teaching about pain in the elderly when one of the students replies:

"Pain is a natural part of aging." Rationale: Pain is prevalent in older adults; however, some of them mistakenly believe pain to be a normal part of aging. Older clients may be afraid to report pain for many different reasons. They may not want pain to interfere with their independence. They may worry that medical attention to their pain will lead to costly tests. They also may fear that healthcare providers will not see them as "good" clients if they mention pain, and so they try to mask it.

The nurse administers pain medication to a client at 1600. At what time should the nurse return to reassess the client's pain level?

1630 rationale: Pain should be assessed every 4 hours; reassessments after interventions should be done in 30 minutes after intervention.

A nursing instructor is teaching students how to assess a client's pain. The instructor emphasizes that there are many misconceptions about pain. The instructor realizes that a student needs further direction when the student states:

"nurses are the best authority on pain" Rationale: Pain is what the client says it is, and it exists whenever the client says it does. The client is the best authority on pain, and self-report is the gold standard.

A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence?

'He tells me that he is sorry and that he will never hit me again." Rationale: During phase 3 of the cycle, the perpetrator becomes kind, contrite, and loving, begging for forgiveness and promising never to inflict abuse again until the next time. The actual violence occurs in phase 2. Yelling at the client for not having dinner ready and calling her stupid and incompetent reflect phase 1 or tension building.

A nurse is establishing an ideal body weight for a 5' 9" healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight?

145lbs rationale: A general guideline, often called the rule-of-thumb method, determines ideal weight based on height. This formula is as follows: •For adult females: 100 lb (for height of 5 ft) + 5 lb for each additional inch over 5 ft •For adult males: 106 lb (for height of 5 ft) + 6 lb for each additional inch over 5 ft.

Which of the following clients will have an increased metabolic rate and require nutritional interventions?

A person with a serious infection and fever. Rationale:Factors that increase metabolic rate include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of some hormones. Aging, prolonged fasting, and sleep decrease metabolic rate.

As a nurse is adjusting a client's hospital bed, the nurse accidently pinches a finger between the bed and the wall. Which of the following components is involved in the transduction of the pain the nurse feels?

A-delta and C fibers Rationale: The nurse is experiencing nociceptive or somatic pain. A-delta fibers are large nerve fibers covered with myelin that conduct pain impulses rapidly. The sharp or stabbing pain the nurse feels as the finger is pinched involves these fibers. C fibers are smaller, unmyelinated nerve fibers that conduct pain impulses more diffusely and slowly. The achy pain that lingers after the nurse has withdrawn the finger—that the nurse might "shake off"—involves these fibers. Neuronal plasticity refers to changes in pain signal processing due to a prolonged stimulus; the result is chronic sensation of pain after the original stimulus is removed. There are no "K-fibers" or "L-beta fibers."

A client presents to the emergency department after falling off a ladder and reports pain in the right shoulder. He says that he has not taken anything for the pain yet. The nurse recognizes this as what type of pain?

Acute pain Rationale: Acute pain is pain associated with an injury with a recent onset and duration of less than 6 months. Intractable pain is pain that is highly resistant to pain relief. Because no pain relief has yet been attempted with this client, there is not enough evidence to know whether the pain is intractable. Chronic pain is pain that persists longer than 6 months. Visceral pain is pain experienced in a deep organ, typically in the abdominal cavity, thorax, or cranium.

During a lecture on pain management, the nursing instructor informs the group of nursing students that the primary treatment measure for pain is which of the following?

Analgesics Rationale:Analgesics are most often the primary treatment measure for pain, although a growing trend involves the integration of complementary, nonpharmacologic measures with conventional medicine.

The nurse suspects a child is a victim of abuse. What observation caused the nurse to make this clinical determination?

Appears younger than stated age Rationale: Abused children may appear younger than the stated age due to developmental delays or malnourishment. Mussy hair, a hole in the shirt, and wearing shorts and tennis shoes are not observations that indicate that the child is a victim of abuse.

Unilateral ptosis of an eye would occur because of repeated injuries to the eye causing nerve damage to the eyelids. This finding does not indicate an undiagnosed eye or neurologic disease. This finding does not indicate the need for corrective lenses.

Ask the father to leave the room so that the nurse can talk with the child in private Rationale: Creating a safe and confidential environment is essential to obtain concise and valid subjective data from any client who has experienced family violence. For any client over the age of 3 years, ask screening questions in a secure, private setting with no one else present in the room. Do not screen if there are any safety concerns for you or the client. To postpone the screening could jeopardize the child's safety, so the nurse should ask the father to leave the room.

A nurse is assigned to care for a client who has been physically abused by her husband. The nurse finds that client has an abuse score of 4 in her documents. Which of the following descriptions corresponds to the abuse score? Beating up and severe contusions Punching and kicking Head injury and internal injury Threat of abuse by weapons

Beating up and severe contusions Rationale:An abuse score of 4 corresponds to beating up and severe contusions. Punching and kicking are given a score of 3. Head injury and internal injury are rated a score of 5. Threat of abuse by weapons is given a score of 1.

The nurse should assess for which pain complaints from a client diagnosed with Type II Diabetes Mellitus?

Burning, tingling Rationale: The nurse should assess for neuropathic pain associated with diabetic neuropathy. Neuropathic pain: Pain that results from damage to nerves in the peripheral or central nervous system (Staats, et al., 2004). Examples of neuropathic pain include diabetic peripheral neuropathy, post herpetic neuralgia, and postmastectomy pain. You should also be alert for the common terms that clients use to report neuropathic pain, such as burning, painful tingling, pins and needles, and painful numbness.

A nurse is examining a 16-year-old girl who is visibly distraught. The client has a bruise on her face and tells the nurse that her boyfriend got rough with her recently. On further questioning, the client tells the nurse that her boyfriend raped her. Which of the following is the priority nursing intervention at this point? Apply ice to the bruise on the client's face to reduce swelling Conduct a forensic interview Assess the client for signs of psychological abuse Determine whether the boyfriend was abused as a child

Conduct a forensic interview

During a home visit an older client asks the nurse to find out what papers the client signed "the other day." What should the nurse do first?

Continue to assess for indications of abuse or neglect Rationale: Signing papers that the older client did not understand is the first question to assess for elder abuse or neglect. The nurse should continue to assess for indications of abuse or neglect. Assessing for signs of physical abuse can be done later. A complete mental health assessment does not need to be done at this time. Asking the client for the name of the person who had the papers to sign can be obtained later.

The nurse is caring for a woman in the prenatal clinic who comments that she just cannot seem to get things "right" anymore at home and that her husband says she knows so little about life. Which type of abusive or controlling behavior is the woman describing?

Emotional abuse

The nurse is working on a pediatric unit caring for a 4-year-old who is recovering from the surgical repair of the pelvis. When assessing the client's pain, what is the most appropriate pain assessment tool for the nurse to use?

FACES Pain Scale Rationale: Children 2 years and older can identify pain and point to its location. You can use a facial expression scale for children starting at approximately 3 years. The FACES scale uses six faces ranging from happy with a wide smile to sad with tears on the face.

The nurse is caring for a 4-week-old postoperative client. The most appropriate pain assessment tool would be the:

Face, Legs, Activity, Cry, Consolability Scale

A nurse assesses a cognitively impaired adult client who grimaces and points to the right knee following a motor vehicle accident. Which pain scale would be most appropriate for the nurse to use to assess the client's pain?

Faces Pain Scale Rationale: The nurse should use the Faces Pain Scale (FPS) to rate the pain felt by the client. The FPS shows different facial expressions; the client is asked to choose the face that best describes the intensity or level of pain being experienced. This tool is best suited for cognitively impaired adults. A Verbal Descriptor Scale (VDS) ranges pain on a scale between mild, moderate, and severe. The Numeric Rating Scale (NRS) rates pain on a scale from 0 to 10: 0 reflects no pain and 10 reflects pain at its worst. It has been shown to be best for older adults with no cognitive impairment. The Visual Analog Scale (VAS) rates pain on a 10-cm continuum numbered from 0 to 10: 0 reflects no pain and 10 reflects pain at its worst. These scales would require verbal communication between the client and the nurse.

The nurse is concerned that an older community member is being abused by an adult son however will not report the abuse or seek help. What could be a reason for this older adult to refrain from reporting the abuse?

Fear of being institutionalized Rationale: Elder abuse is often difficult to assess because of the older person's hesitancy to report the abuse. Reasons why abuse is not reported include the fear of being institutionalized. Other reasons why the abuse is not reported include mistrust of law enforcement, family relationship that may create feelings of guilt, burden, dependence, of fear of abandonment. It is unlikely that the abuse is not being reported because the abuse is not that bad, the older adult loves the son, or because the son provides companionship.

The nursing student asks the nurse what would be an example of visceral pain. What would be the correct response by the nurse?

Gallbladder pain Rationale: Visceral pain originates from abdominal organs, such as the gallbladder. Burns cause cutaneous pain, which is derived from the dermis, epidermis, and subcutaneous tissues. Referred pain originates from a specific site, but is experienced in another site along the innervating spinal nerve, such as occurs with cardiac pain. Somatic pain originates from skin, muscles, bones, and joints, such as arthritic pain.

When reviewing a client's medication administration record, the nurse should plan to administer a medication containing which substance that blocks pain sensations? -Substance P -Bradykinin -Glutamate -Gamma-aminobutyric acid

Gamma-aminobutyric acid Rationale: Pain-facilitating substances: •Substance P •Bradykinin •Glutamate Pain-blocking substances: •Serotonin •Opioids (both natural and synthetic) •Gamma-aminobutyric acid: gabapentin (Neurontin) and pregabalin (Lyrica)

After assessing a client and finding her positive for intimate partner violence (IPV), which of the following should the nurse do next?

Have the client fill out a danger assessment questionnaire Rationale: If screening for IPV is positive, the nurse should ask the client to fill out a danger assessment questionnaire. If screening for IPV is positive and the client's answers on the danger assessment questionnaire indicate a high probability for serious violence, the nurse should ask the client if she has a safety plan and where she would like to go when she leaves the nurse's agency. A follow-up appointment should be scheduled and/or the client should be referred as appropriate. Interviewing the client and recording subjective and objective findings would have already been completed as part of the assessment.

A client complains of pain in several areas of the body. How should the nurse assess this client's pain?

Have the client rate each location separately. Rationale: When assessing pain location, ask the client to point to the painful area. If more than one area is painful, have the client rate each one separately, and note which area is the most painful. Marking each site is not necessary practice for assessing pain. Pain is a subjective sensation for the client. Radiating pain is notable, because such radiation may affect treatment choices.

A nurse is assessing the effect of a client's chronic back pain on his affective dimension. Which question should the nurse ask for this assessment?

How does the pain influence your overall mood? Rationale:The question regarding the influence of the pain on mood would address the client's affective dimension, which includes feelings and emotions that result from the pain. The question regarding medical conditions would help assess the client's physical dimension. The question regarding the location of the pain would address the client's sensory dimension. The question regarding the client's education would address his cognitive dimension.

The nurse notes that an adolescent male has ptosis of the left eye. What should the nurse suspect as the reason for this finding?

Nerve damage caused by repeated eye injuries Rationale: Unilateral ptosis of an eye would occur because of repeated injuries to the eye causing nerve damage to the eyelids. This finding does not indicate an undiagnosed eye or neurologic disease. This finding does not indicate the need for corrective lenses.

A client describes pain in the soles of both feet as constantly burning. Which type of pain should the nurse suspect this client is experiencing?

Neuropathic Rationale: Pain resulting from direct injury to the peripheral or central nervous system is termed neuropathic. Over time, neuropathic pain may become independent of the inciting injury and be described as burning. Somatic pain originates from skin, muscles, bones, and joints and is usually described as sharp. Referred pain is pain felt in a body area, away from the pain source. Visceral pain originates from abdominal organs and is usually described as cramping or gnawing.

A client expresses to the nurse visiting her home that her husband has threatened to kill her. The nurse understands that threats of harm and intimidation are which type of abuse?

Psychological Rationale: Threat to harm and intimidation are examples of psychological abuse. Economic abuse includes forging signatures. Physical abuse includes direct physical violence with harm inflicted. Sexual abuse includes fondling.

In addition to pain intensity, what is another basic element of a pain assessment?

Quality

The client comes to the emergency department reporting indigestion and left arm pain. The physician orders an EKG along with drawing of cardiac enzymes. When the results are back, the client is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following?

Referred Pain Rationale: Referred pain originates from a specific site, but the person feels the pain at another site along the innervated spinal nerve. An example is cardiac pain that the person experiences as arm pain and indigestion. Visceral pain originates from abdominal organs. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. Somatic pain originates from skin, muscles, bones, and joints.

A nurse is providing nutritional instruction at a health fair. She instructs passersby on the characteristics of a nutrient that is the body's first source of energy, sparing use of other nutrients for this purpose, that raises the blood glucose level, is found in fruit juices, and that can be converted quickly into energy. To which of the following nutrients is the nurse referring?

Simple Carbohydrates Rationale: Briefly, carbohydrates are referred to as either simple or complex, depending on their chemical structure. Simple carbohydrates, such as found in fruit juice, are sugar with a simple structure that raises the blood glucose level and can be converted quickly into energy. Complex carbohydrates, such as whole grains, are starches that more slowly convert into energy and can also be used as an energy source. Carbohydrates are known as protein sparing because the body uses them for an energy source rather than breaking down proteins to fuel the body's energy needs. Protein and fat can be used as energy sources but are not the body's first source of energy, and are metabolized more slowly.

A nurse is using calipers to assess a client. Which of the following measurements is the nurse taking?

Skinfold Thickness Rationale: Skinfold calipers are used to measure triceps skinfold thickness to evaluate the degree of subcutaneous fat stores. Body mass index is calculated by first measuring height and weight by means of a balance beam scale with height attachment and then entering these values into a formula. A tape measure is used to measure waist and mid-arm circumferences.

A client recovering from abdominal surgery is complaining of pain. The nurse realizes that the client is most likely experiencing which type of pain?

Somatic Rationale: Somatic pain is caused by tissue damage, which would occur after abdominal surgery. Psychogenic pain relates to factors that influence the client's report of pain such as anxiety and depression. Idiopathic pain does not have an identified cause. Neuropathic pain results from direct injury to the peripheral or central nervous system.

A cyclist reports to the nurse that he is experiencing pain in the tendons and ligaments of his left leg, and the pain is worse with ambulation. The nurse will document this type of pain as which of the following?

Somatic pain Rationale: Somatic pain is diffuse or scattered pain, and it originates in tendons, ligaments, bones, blood vessels, and nerves. Cutaneous pain usually involves the skin or subcutaneous tissues. Visceral pain is poorly localized and originates in body organs. Phantom pain occurs in an amputated leg for which receptors and nerves are clearly absent, but the pain is a real experience for the client.

A cyclist reports to the nurse that he is experiencing pain in the tendons and ligaments of his left leg, and the pain is worse with ambulation. The nurse will document this type of pain as which of the following?

Somatic pain Rationale: somatic pain is diffuse or scattered pain, and it originates in tendons, ligaments, bones, blood vessels, and nerves. Cutaneous pain usually involves the skin or subcutaneous tissues. Visceral pain is poorly localized and originates in body organs. Phantom pain occurs in an amputated leg for which receptors and nerves are clearly absent, but the pain is a real experience for the client.

When describing an episode, the victim reports that she attempted to calm her partner down to keep things from escalating. This behavior reflects which phase of the cycle of violence?

Tension-Building Rationale: During the first phase, tension-building, the woman attempts to keep the situation from exploding based on her belief that the partner's anger is legitimately directed at her. The battering phase involves the explosion of violence. The honeymoon or reconciliation phase is manifested by a period of calm, loving, contrite behavior on the part of the batterer. The batterer may be genuinely sorry for the pain he caused.

The nurse observes the spouse of a client pinch the client's arm when someone talks with the client in the waiting room of the community clinic. What should this observation indicate to the nurse?

The client is not permitted to have contact with others

Mark is a 20-year-old college student who has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is Mark most likely experiencing?

Visceral pain Rationale: Visceral pain occurs when organs stretch abnormally and become distended, ischemic, or inflamed. Appendicitis is characterized by inflammation of the vermiform appendix. Cutaneous pain is superficial and somatic pain is more commonly associated with tendons, ligaments, and bones. Referred pain is perceived distant from its point of origin, but this client's pain is sensed near the location of his appendix.

A client presents to the ED with pain in the upper right quadrant that worsens after eating. The client describes the pain as sharp, stabbing, and at times very intense. This is a description of which type of pain?

acute Rationale: Acute pain results from tissue damage, whether through injury or surgery. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. Phantom pain is pain in an extremity or body part that is no longer there. Cutaneous pain and phantom pain are not described as above. Chronic pain, also known as persistent pain, is a description of a pain that is present for more than six months, and can be described in many different terms, not just as above.

A client rates the current pain level as being a 5 on the Numeric Rating Scale. How should the nurse document this pain assessment?

client rated pain level as being a 5 using the rating scale. Rationale: The nurse should document the exact pain assessment finding which would be client rated pain level as being a 5 using the rating scale. The statement "client experiencing a moderate amount of pain" is a subjective statement made by the nurse and is inaccurate. The statement "client experiencing mild pain" is a subjective statement made by the nurse and is inaccurate. The statement "client stated pain level not that bad" is a subjective statement made by the client however does not identify that the client rated the pain level as being a 5 on the Numeric Rating Scale.

In her assessment of a client, a nurse finds that the client has soft, spongy, and bleeding gums. The nurse recognizes that this client most likely has a deficiency in which of the following?

vitamin C Rationale: Soft, spongy, and bleeding gums are a sign of vitamin C deficiency. Iron deficiency is associated with spoon-shaped, brittle, or rigid nails. Vitamin B12 deficiency is associated with a beefy, red tongue. Protein deficiency is associated with thinning, dry hair, edema, and ascites.